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 Erectile Dysfunction (Impotence)

The inability of the male to achieve an erection is impotence (a better terminology is ‘erectile dysfunction’ or ED). Male erection is a neurovascular reflex that depends on the healthy anatomy of penis with an ideal hormonal environment. Impotence is of two types: primary (ED from the beginning and secondary (initiates after a period of normal penile erection).

BASICS OF ERECTILE DYSFUNCTION

Three basic mechanisms needed to develop  Erectile Dysfunction

1. Failure to initiate (psychogenic, endocrinologic, or neurogenic), or

2. Failure to fill (arteriogenic), or

3. Failure to store (venoocclusive dysfunction) sufficient volume of blood within the lacunar network of penis.

Multiple factors contribute to ED in many patients. Diabetes mellitus, atherosclerosis, and drug-related aetiologies are responsible for major causes of ED in older people.

Galactorrhea: Causes Symptoms diagnostic StudiesTreatment

POSSIBLE ASSOCIATIONS OF ERECTILE DYSFUNCTION

Psychological (i.e. situational) 

Variety of psychogenic inputs like anxiety, depression, sexual inhibition, sexual abuse in childhood, fear of pregnancy/STD, sense of guilt, ignorance of sex act, conflicted parent-child relationship or religious orthodoxy.

Organic (i.e. constitutional)

a. Endocrine–Kallman’s syndrome, hypopituitarism, hyperprolactinaemia, pituitary tumour, Klinefelter’s syndrome, testicular tumour/trauma/orchitis, alcoholic liver disease induced testicular atrophy, hypogonadism, andropause, Addison’s disease, hypo- or hyperthyroidism.

b. Diabetes mellitus (DM-associated neurologic, as well as vascular complications, are responsible for ED in 35-75% patients).

c. Vascular–atherosclerosis (e.g. Leriche’s syndrome) or traumatic arterial disease.

d. Neurogenic–autonomic neuropathy (e.g. from DM), cauda equina lesion, multiple sclerosis, peripheral neuropathy (e.g. alcoholism), following pelvic surgery, spinal cord injury, alcohol excess.

e. Drug-induced–antihypertensives, antidepressants, tranquilizers, psychotropics, anticholinergics, cytotoxic drugs, hormones (e.g.oestrogens), β-blockers.

f. Miscellaneous –– recreational drugs or addictions, alcohol, cocaine, marijuana), chronic debilitating diseases (chronic renal failure, motor neurone disease), pelvic fracture, mechanical interference from morbid obesity, prostatectomy, Peyronie’s desease.

CLINICAL EVALUATION OF ERECTILE DYSFUNCTION

A close-door sympathetic interview with the patient is the first task of the physician. Differentiate organic from psychological cause; ED with only one partner, of sudden onset, intermittent (i.e. not permanent), with ability to masturbate, having nocturnal and early morning erections, and with normal nocturnal penile tumescence test (a plethysmograph placed around the penis overnight to determine the neurovascular action sufficient to produce erection during sleep) suggest psychogenic ED. Other aspects of history should focus on duration and persistence of ED, symptoms suggestive of endocrine disorders, neuropathy, vascular disease or diabetes.

Normal levels of testosterone, gonadotrophin and prolactin with history of nocturnal emissions and frequent satisfactory morning erections make endocrine disorders unlikely. A careful history of stress, alcohol abuse, drugs (mentioned above) should be taken.

Details physical examination of BP, thyroid, liver, CVS, renal system should be sought for. Size of testicles and penis (e.g. priapism), secondary sexual characters, and testing of peripheral neuropathy must be done.

In selected patients, specialized testing may give clues to diagnosis:

a. Studies of ‘nocturnal penile tumescence (NPT)’ and rigidity.

b. Vascular testing (penile doppler USG, penile angiography, dynamic infusion covernosometry).

c. Neurologic testings (vibratory perception; so called somatosensory evoked potentials).

d. Psychological diagnostic tests. 

It is important to remember that, psychogenic ED is frequently a diagnosis of exclusion.

* Reduced libido: hypogonadism and depression         Intact libido: others including psychological problems

** NPT test is normal in psychogenic ED.

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TREATMENT OF ERECTILE DYSFUNCTION (IMPOTENCE)

1. Patients education is started with gynaecological examination of the female partner to rule out any obstructive pathology in female genital tract. Psychiatric examination of both partners is mandatory. It is important to discuss the matter frankly with the patient.

2. Drugs–Phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil) ↑ penile blood flow and remain the first line of drug therapy in ED; apomorphine, intraurethral or intracavernosal self-injections of alprostadil, papavarine or phentolamine.

3. Androgen therapy–Androgen replacement treatment is used in primary and secondary causes of hypogonadism. Loss of libido is corrected by androgen therapy.

4. Devices–Vacuum constriction devices, insertion of inflatable penile prosthesis or revascularization surgery may be done in selected cases.

5. Sex therapy–It addresses specific interpersonal factors, and consists of in-session discussion and at-home exercises specific to the person and the relationship. Both the partners should be involved in sex therapy to have a favourable outcome.

PREMATURE EJACULATION 

It is the discharge of the semen before the orgasm is attained, i.e. it is an early orgasmic response. If it is persistently or recurrently experienced, one seeks advice of a doctor. The main causes in clinical practice are –

• Psychological (no sexual experience, anxiety)

• Injury to genitourinary tract, genital anomalies or urinary infection (e.g. burning micturition)

• Diabetic autonomic neuropathy (affects parasympathetic control)

• Spinal cord injury.

While treating the patient, the physician should consider duration of excitement phase, age of the patient, frequency and duration of coitus; in the day to day practice, it is seen in young patients with lack of sex knowledge. Usually, it requires no treatment but psychiatric counselling with clearing of myths/misconceptions, or application of anti-anxiety drugs (sertraline, fluoxetine) may be of some help.

CARDINAL ELEMENTS OF NORMAL SEXUAL FUNCTION

Libido (desire)

↓

Erection (lubrication in female)

↓

Intromission

↓

Ejaculation and orgasm (only orgasm in female).

PRIAPISM

It is the unwanted, painful and persistent erection of penis, and is commonly due to:

• Sickle cell anaemia

• Hypercoagulable states

• Chronic myeloid leukaemia

• Spinal cord injury

• Injection of vasodilators (e.g. papavarine) into penis

• Pelvic vascular thrombosis

• Megapenis.

It is a very embarrassing situation for the patient. To treat the first 3 causes, analgesics, hydration and α-adrenergic blockers are used. In others, treatment of the aetiology is solicited.

RETROGRADE EJACULATION

The process of ejaculation starts by → stimulation of sympathetic nervous system → contraction of vas deferens + seminal vesicles + prostate →seminal fluid entering into urethra, associated with rhythmic contractions of bulbocavernosus and ischiocavernosus muscles → ejaculation follows.

When the internal urethral sphincter remains open during the process of ejaculation, semen enters into urinary bladder and is known as retrograde ejaculation. It is commonly seen in diabetic patients with autonomic neuropathy or after surgery involving the bladder neck.